Cholesterol Control & Heart Health

Heart disease is still the number one killer in America today, despite the billions spent annually on cholesterol-lowering drugs. More than 800,000 people will have a heart attack this year–and over 650,000 will die from a “coronary event.” That’s about one every minute. And nearly half of all heart attack sufferers have normal cholesterol levels.

Americans have been hearing about the evils of cholesterol for at least 60 years. In the early 1960s, the American Heart Association (AHA) warned people that saturated fat was the culprit behind elevated cholesterol levels. We were told that cholesterol in general, and "bad" LDL cholesterol in particular, would clog our arteries and that would lead to heart attacks. If we would just stop eating eggs, red meat, butter, cheese and other full-fat dairy products, we would reduce our risks of cardiovascular disease. 

For decades, cardiologists and nutrition experts encouraged their patients to substitute margarine for butter. Anyone who regularly consumed eggs for breakfast would have been told that this was risky business. That was because the yolks were high in cholesterol.

Americans were advised that a heart healthy breakfast would include pancakes or waffles with margarine and syrup. No cholesterol or saturated fat! Just lots of carbs, which were considered heart healthy. Cereal was recommended as a much better choice than eggs. No matter that many of our favorite cereals were loaded with sugar. If people used skim milk on their cereal, they got a pat on the head and a thumbs up. Yogurt was OK, as long as it was no-fat or low-fat yogurt, which generally meant that there would be a generous dollop of fruit jam at the bottom of the carton. 

Nuts were verboten. They were high in fat and we were repeatedly told that fat was the enemy. Other foods on the no-no list included avocados (also too high in fat) and shrimp (high in cholesterol). We could go on, but by now you get the drift. The bottom line was: fat would make you fat and clog your coronary arteries. 

By now, the problems with most of this advice have been revealed. Margarine is NOT better than butter, and eating eggs a few times a week does NOT raise cholesterol. Although cholesterol is still considered an important risk factor, there are many, many others that may be equally strong.

Some Risk Factors

• High level of C-reactive protein (CRP)
• Smoking
• Hostility or anger
• High LDL cholesterol
• Low HDL cholesterol
• High level of very low-density (VLDL) cholesterol
• High triglycerides
• Elevated lipoprotein (a) known as Lp(a)
• Being overweight
• High homocysteine
• Too much iron
• High blood pressure
• Lack of physical activity
• Genes & family history
• Diabetes & insulin resistance
• High uric acid level
• Depression
• Lack of a social network
• Socio-economic status
• Stress & anxiety
• Hormone Replacement Therapy (HRT)

Many of the so-called heart-healthy foods were not that good for us and many of the vilified items have turned out to be just fine. We will provide documentation momentarily. If it seems as if we have been on a roller coaster ride when it comes to heart health, strap in! It's about to get even more complicated. 

The American Heart Association (AHA) carries a lot of weight with doctors and consumers. It is perceived as a highly objective and trustworthy organization by many people. Here is what the AHA still recommends when it comes to dairy fat:

“AHA Recommendation

• Choose 2–3 servings of fat-free or low-fat dairy products for adults. Children should have two or more servings, teenagers and older adults should have four.
• For dessert or snacks, choose ice milk, frozen or fruited low-fat or nonfat yogurt, sherbet, sorbet or low-fat puddings.

"Choose from:

• Fat-free, zero-fat, no-fat or nonfat milk
• ½–1% low-fat or light milk
• Nonfat or low-fat dry milk powder
• Evaporated fat-free milk
• Buttermilk made from fat-free or 1% fat milk
• Fat-free or low-fat yogurt
• Frozen fat-free or low-fat yogurt
• Drinks made with fat-free or 1% fat milk and cocoa
(or other low-fat drink powders)
• Low-fat cheeses (dry-curd or low-fat, cottage cheese, low-fat natural cheeses or processed cheeses made with nonfat or low-fat milk with no more than 3 grams of fat per ounce and no more than 2 grams of saturated fat per ounce)
• Fat-free or low-fat ice cream (no more than 3 grams of fat per 1/2 cup serving)"

This is the old way of thinking but it is still firmly entrenched. You are supposed to substitute fruited nonfat yogurt or sherbet for dessert. The trouble with such desserts or snacks is that they are high in carbs in the form of sugar! We now know that sugar may be a bigger problem than dairy fat.

Trans Fats vs. Dairy Fat:

Tens of millions of Americans relied upon hydrogenated vegetable oils (trans fats) for their bread spread. It was supposed to be good for your cardiovascular health because there was no cholesterol. We now know that was a horrible idea. Substituting hydrogenated margarine for butter probably caused more heart attacks than it prevented.

There is increasing evidence that a low-fat diet may not be as heart protective as doctors once imagined. But old habits die hard.

The Guardian (Oct. 9, 2015) offers these stats:

“Between 1975 and 2014, sales of whole fat milk have decreased by nearly 61%, while sales of 2% milk have increased nearly 106%. Sales of 1% and skim milk have increased by around 170% and 156%, respectively, according to data from the USDA.”

The Pros and Cons of Dairy Fat:

Despite the AHA’s admonition to avoid dairy fat and saturated fat, here is some science dating back more than a decade:

An article in the American Journal of Clinical Nutrition (March, 2010) provides a shot across the bow of the AHA.

The authors analyzed data over 5-23 years involving 347,747 subjects:

“Results: During 5-23 y of follow-up of 347,747 subjects, 11,006 developed CHD [coronary heart disease] or stroke. Intake of saturated fat was not associated with an increased risk of CHD, stroke, or CVD [cardiovascular disease].

“Conclusions: A meta-analysis of prospective epidemiologic studies showed that there is no significant evidence for concluding that dietary saturated fat is associated with an increased risk of CHD or CVD.”

In 2012 researchers published a study of “the consumption of dairy fat and high-fat dairy foods, obesity, and cardiometabolic disease” (European Journal of Nutrition, July 19, 2012):

“Results: In 11 of 16 studies, high-fat dairy intake was inversely associated with measures of adiposity. Studies examining the relationship between high-fat dairy consumption and metabolic health reported either an inverse or no association. Studies investigating the connection between high-fat dairy intake and diabetes or cardiovascular disease incidence were inconsistent.

“Conclusions: The observational evidence does not support the hypothesis that dairy fat or high-fat dairy foods contribute to obesity or cardiometabolic risk, and suggests that high-fat dairy consumption within typical dietary patterns is inversely associated with obesity risk.”

We apologize for being obvious. Inverse means that eating dairy fat did not make people fat. If anything, it was associated with less obesity.

That message was reinforced by this study published in the Scandinavian Journal of Primary Health Care (June, 2013):

“Conclusion: A high intake of dairy fat was associated with a lower risk of central obesity and a low dairy fat intake was associated with a higher risk of central obesity.”

These results were confirmed in the Luxembourg Study (Nutrition Research, Nov. 2014):

“Participants in the highest tertile of whole-fat dairy intakes (milk, cheese, yogurt) had significantly lower odds for being obese; abdominal obesity, compared with those in the lowest intake tertile, after full adjustment for demographic, lifestyle, dietary, and cardiovascular risk factor variables. Increasing consumption of dairy foods may have the potential to lower the prevalence of global and abdominal obesity.”

Not all of the research is decades old. A recent review of prospective studies on major health outcomes found that people eating cheese frequently were less likely to die prematurely, develop heart disease or experience a stroke (Advances in Nutrition, Sep. 2023).

The authors of this study conclude

"Our findings suggest that cheese consumption has neutral to moderate benefits for human health."

Saturated Fat and Heart Disease:

In 2014, a study was published in the highly regarded Annals of Internal Medicine (March 18, 2014). The authors reviewed 72 studies. There were more than 600,000 participants in these studies:

The conclusions challenged the AHA’s attack on dairy fat and love affair with polyunsaturated fatty acids. Those are the fats found in vegetable oils like safflower oil, peanut oil and sunflower oil.

The investigators wrote:

“Conclusion: Current evidence does not clearly support cardiovascular guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of total saturated fats.”

You can read more about this study and other recent studies that contradict the AHA at this link:

Has the Flip-Flop on Saturated Fat Made Your Head Spin?

One risk factor associated with heart disease is metabolic disruption in the form of diabetes or prediabetes. Not long ago, Austrialian scientists completed a twelve-year long study observing nearly 5,000 people (Journal of Nutrition, June 2023). All the participants had normal glucose tolerance at the beginning of the study. They answered questions about their diets at a few points during the study and also had their blood glucose measured. Those who consumed full-fat milk, cheese or yogurt were less likely to have developed prediabetes.

The investigators note:

"In this large Australian cohort, protective associations were found for high-fat dairy types, whereas neutral associations were seen for low-fat dairy types. Studies with more detail on sugar content of types of dairy foods and products eaten with dairy foods (e.g., cereals or jam), and studies into potential causal mechanisms of the health effects of dairy intake are required."

Saturated Fat vs. High-Carb Foods:

Remember how we suggested that the old “heart-healthy” breakfast of pancakes, waffles or sugary cereals was worse than a breakfast high in dairy fat? The PURE (Prospective Urban Rural Epidemiology) study collected dietary data from 135,000 people. It confirmed this concept.

After seven years, the people who followed a high-carb diet were more likely to have died or developed health problems than those consuming a high sat-fat diet. Read about this and other contradictory data at this link:

Just How Scary Is Saturated Fat?

What About Olive Oil?

By now you have heard that adding olive oil to the diet benefits the heart. Did you know that olive oil is 14% saturated fat? The low-fat gurus continue to insist that olive oil is unhealthy.

The latest study challenges them, however. It was published in one of the preeminent heart publications, the Journal of the American College of Cardiology (January 18, 2022).

In the Nurses’ Health Study, 60,582 women completed questionnaires about their diets, their activities and their health every few years between 1990 and 2018. During the same time frame, the Health Professionals Follow-up Study collected that information from 31,801 men.

In total, 36,856 of these 92,383 volunteers died in the course of the study. People consuming more olive oil were less likely to die, even after adjusting for age. By comparing the extremes–people who ate the most olive oil to those who ate the least–the investigators determined that olive oil lovers were 19 percent less likely to die of heart disease.

How Much Olive Oil Is Heart Healthy?

Those at the highest level of consumption were getting at least 7 grams of olive oil daily. How much, you may wonder, is that? It turns out that a tablespoon of olive oil comes in just under 14 grams, so 7 grams is a bit more than half a tablespoon.

Besides cardiovascular health, people eating more olive oil were also less likely to die of cancer (17 percent), neurodegenerative disease (29 percent) or respiratory disease (18 percent). The scientists calculated whether people would benefit by substituting olive oil for margarine, butter or other dairy fat. They suggest that olive oil is more healthful than animal fats.

More Support for Olive Oil:

This is not the first study to conclude that olive oil can help heart health. One famous trial was known as PREDIMED (New England Journal of Medicine, June 21, 2018). In it, more than 7,000 Spaniards at high risk of heart disease were asked to follow three specific diets for nearly five years.

One group followed a Mediterranean-style diet rich in vegetables, fish and legumes, to which they added four tablespoons of extra-virgin olive oil daily. Another group also consumed a Mediterranean diet, but instead of olive oil, they added an ounce of almonds or hazelnuts to their daily fare. The third group served as a control and followed a low-fat cardiologist-recommended diet to the best of their ability.

People in both the olive oil and the nut dietary groups were significantly less likely to have a heart attack, stroke or death from a cardiovascular cause. In addition, women in the olive oil group were less likely to be diagnosed with breast cancer (JAMA Internal Medicine, Nov. 2015).

If olive oil and a Mediterranean diet were pills, doctors would prescribe them for everyone and the drug companies would charge a lot of money. And when I say a lot of money I mean thousands of dollars a month! Instead, you can help yourself to health at your local grocery store or farmers' market by eating real food.

Deaths from Heart Disease

The good news is that deaths from heart disease have been dropping for decades. And cholesterol levels have also been coming down. But, we shouldn’t break out the party hats and confetti prematurely, because the news could be a lot better. According to the CDC, heart disease is still the number one cause of death in America. That is despite the American Heart Association's dietary recommendations and its guidelines encouraging statin use in almost anyone with "risk factors." Here are the scary CDC stats:"

• "One person dies every 36 seconds in the United States from cardiovascular disease.
• About 659,000 people in the United States die from heart disease each year—that’s 1 in every 4 deaths.
• In the United States, someone has a heart attack every 40 seconds.
• Every year, about 805,000 people in the United States have a heart attack. Of these,
  • 605,000 are a first heart attack
  • 200,000 happen to people who have already had a heart attack
  • About 1 in 5 heart attacks is silent—the damage is done, but the person is not aware of it."

The Heart Disease Dilemma:

There is no doubt that heart disease remains a huge health problem in the US. There is still a lot of confusion and contradiction. What used to be written in stone has crumbled. The connection between cholesterol and heart disease may be far more complicated than we’ve been led to believe.

The manufacturers of cholesterol-lowering drugs like Lipitor (atorvastatin), Livalo (pitavastatin), Crestor (rosuvastatin), and Zocor (simvastatin) would certainly like us to think that high cholesterol causes heart attacks, and conversely that by lowering cholesterol, one eliminates the risk of a major coronary event. They seem to have convinced a lot of people: these drugs have been among the most profitable in the history of pharmaceuticals. We would like nothing more than if popping a pill could prevent a heart attack with no adverse side effects. Unfortunately, the reality is a bit fuzzier.

As it turns out, the cholesterol dogma may be wrong in all kinds of ways. For one thing, the notion that eating a diet high in cholesterol–full of eggs, meat, and fats–is a cardinal cholesterol sin, sure to send you straight to the ER, has been reexamined in the wake of contrary evidence. Several studies have shown that a low-carb diet, like Atkins or the Zone, led to greater weight loss, reduction in serum triglycerides, and an increase in good HDL cholesterol than a low-fat diet. 

Higher-fat diets seem to raise good HDL cholesterol better than low-fat diets, which may help explain why they also seem to give those following them better scores on heart-disease risk factors than those on Dean Ornish-style low-fat, carbohydrate-heavy diets.

And contrary to the medical community’s long-held belief that low-fat = good health, several high-profile studies, including the Women’s Health Initiative with over 48,000 female participants over 50 years old, have demonstrated no statistically significant benefit to a low-fat, high-veggie diet for lowering the risks of heart attack, stroke, breast cancer and colorectal cancer.

Another startling discovery to come out of studies on cholesterol is that daring to push it as low as you can go may indeed be a gamble. Some people are very surprised to learn that our bodies need cholesterol to function: it’s the building block for things like vitamin D and sex hormones such as estrogen and testosterone. It’s also vital for our nervous systems, particularly in the brain. When there isn’t enough cholesterol in your body, synapses (the way neurons communicate with other neurons) break down. As you might imagine, then, having too little cholesterol may also be a bad thing.

At least two studies have provided evidence that there may be a link between very low cholesterol and the risk of bleeding stroke, especially for women with high blood pressure. One study of Japanese-American men found that those with the lowest cholesterol levels were more likely to die earlier. Those with cholesterol in the 188-209 range seemed to fare better. For people over 70, especially women, trying to bring cholesterol down aggressively might be counterproductive. There is very little evidence that lowering cholesterol in an older woman will extend her life expectancy significantly.

Of course, none of this is meant to suggest that we shouldn’t pay attention to our lipid levels, or that we should gorge on hot dogs and hot fudge sundaes. Cholesterol that is too high is clearly dangerous and can lead to an increased risk for heart attack. But what has become clear through the haze of cholesterol confusion is that how much fat you eat matters much less than what kind.

While we always advocate trying nondrug approaches first—the risk of side effects, interactions, complications, and complacency are much lower when we don’t depend on pharmaceuticals to do our bidding for us—sometimes we all need a little bit of extra help. This is also true when it comes to protecting the heart. And our first drug of choice for cardiovascular fitness and protection is aspirin.

Laura Effel’s strategy for lowering her LDL cholesterol 44 points in 5 weeks

One of the listeners to our radio show, Laura Effel, called and later wrote in to us to tell us the remarkable story of how she used dietary changes to bring down her bad LDL cholesterol, and to keep it down.

Laura didn’t want to take the Zocor her doctor had prescribed, as she’d heard some reports of people having bad reactions to statins, like muscle weakness. So with the help of a food scientist and the “skeptical” go-ahead from her doctor, she radically and permanently changed her diet. Here’s what she did:

• Avoided blood-sugar spikes
• Eliminated refined carbs
• Ate a high-protein breakfast
• Substituted olive oil for other fats
• Added soluble fiber to meals other than breakfast
• Focused on fish
• Drank green tea
• Consumed antioxidants
• Stopped eating before bed

After following this new dietary regimen, Laura’s cholesterol not only dropped 44 points in five weeks, it continued to go down. We heard from her three months later, and her LDL had gone down a total of 70 points from its peak of 155.

This approach may not have the same dramatic effect for everyone as it did for Laura, but it certainly can’t hurt to try it!